nourish

This week-long immersive experience will support you in developing more clarity, confidence, and a deeper sense of connection. Through holistic ritual, mindset coaching, embodiment practices, and cultural immersion you'll discover how you can create more balance and inspiration in your life on a daily basis.

Please fill out the form below:

Name *

Name

First Name

Last Name

Email *

Phone *

Phone

(###)

###

####

Where do you live? *

What is your date of birth? *

What is your date of birth?

MM

DD

YYYY

How would you describe your satisfaction with life right now? Please elaborate as much as you’d like. *

By the end of this retreat, how do you want to feel? What results do you want to see? *

We want to curate wellness and self-development workshops and experiences that specifically cater to you. What part of life is the most challenging right now? Please elaborate as much as possible.

Do you prefer a private room, or would you like to share with a roommate? *

Private Room

Shared Room

We have two retreats planned - one for 11/24/19 - 11/30/19, and the other for the week of 12/1/19 - 12/7/19... Do either of these dates work for you? Please anticipate a 2-3 day buffer, to settle in and adjust after your travel. *

11/24/19 - 11/30/19

12/1/19 - 12/7/19

Both would work for me

Not sure yet

The investment for this retreat averages $2,500 USD - is this within your means? *

Is this your first time attending a residential retreat? If not, how many retreats have you been on? *

Have you ever been to Bali before? *

Yes

No

Are you taking any prescription medication right now, or have you over the last 6 months? If so, please describe. *

Have you experienced any serious illness, or major trauma, in the last 5 years? If so, please describe. *

Do you have any questions or concerns you’d like to express? *

How did you hear about this retreat?

After reviewing your application we will ring you for a 15 min discovery call prior to an invitation to attend. What is the best time of day to reach you via phone? *